Monthly variation of unfinished nursing care at the US Army burn center

Unfinished nursing care (UNC) is a problem of time scarcity and has been classified as an error of underuse. More than half of hospital nurses (52-98%) report leaving at least one element of care unfinished due to time scarcity. Relationships between UNC, nursing staff supply, and working conditions were identified in previous cross sectional studies at civilian hospitals; no studies occurred in the burn care or military environments. The purpose of this study was to identify the prevalence and patterns of UNC in relation to variations in nursing staff supply and working conditions at the US Army Burn Center. Registered nurses and licensed vocational nurses working at the 40-bed burn center were asked to complete a 50-item, paper survey once a month for six months. Administrative data related to nursing staff supply and working conditions (e.g., supply/demand ratio, patient turnover, and overtime paid) were collected. Descriptive statistics and multilevel modeling were used in the analysis. The mean response rate for the survey was 44.9% (n = 36-50). Cronbach’s alpha was .96-.98. Each month, 85.7%-100% of all nurses reported leaving at least one element of care unfinished. The mean composite score on the Perceived Implicit Rationing of Nursing Care instrument was 1.69-2.27. Elements of care most frequently left unfinished were: documentation of care, emotional support, and reviewing interdisciplinary documentation to inform nursing care. Elements of care least frequently left unfinished were: the provision of enteral/parenteral nutrition, monitoring patient safety, and having important conversations with staff, family, or the patient. Only nursing care hours provided by float staff significantly predicted nurse estimates of UNC, [beta] = .008, p < .05, R² = .021. These results indicated that the prevalence and patterns of UNC were consistent with findings in previous studies of UNC. This was first study to describe variations in UNC over time and the first to measure UNC in the burn and military environments. Implications for practice, policy, education, and research were discussed.Nursin

An Assessment of Pre-deployment Training for Army Nurses and Medics

ABSTRACT Introduction Although military nurses and medics have important roles in caring for combat casualties, no standardized pre-deployment training curriculum exists for those in the Army. A large-scale, survey-based evaluation of pre-deployment training would help to understand its current state and identify areas for improvement. The purpose of this study was to survey Army nurses and medics to describe their pre-deployment training. Materials and Methods Using the Intelink.gov platform, a web-based survey was sent by e-mail to Army nurses and medics from the active and reserve components who deployed since 2001. The survey consisted of questions asking about pre-deployment training from their most recent deployment experience. Descriptive statistics were used to analyze the results, and free text comments were also captured. Results There were 682 respondents: 246 (36.1%) nurses and 436 (63.9%) medics. Most of the nurses (n = 132, 53.7%) and medics (n = 298, 68.3%) reported that they were evaluated for clinical competency before deployment. Common courses and topics included Tactical Combat Casualty Care, Advanced Cardiac Life Support, cultural awareness, and trauma care. When asked about the quality of their pre-deployment training, most nurses (n = 186; 75.6%) and medics (n = 359; 82.3%) indicated that their training was adequate or better. Nearly all nurses and medics reported being moderately confident or better (nurses n = 225; 91.5% and medics n = 399; 91.5%) and moderately prepared or better (nurses n = 223; 90.7% and medics n = 404; 92.7%) in their ability to provide combat casualty care. When asked if they participated in a team-based evaluation of clinical competence, many nurses (n = 121, 49.2%) and medics (n = 180, 41.3%) reported not attending a team training program. Conclusions Most nurse and medic respondents were evaluated for clinical competency before deployment, and they attended a variety of courses that covered many topics. Importantly, most nurses and medics were satisfied with the quality of their training, and they felt confident and prepared to provide care. Although these are encouraging findings, they must be interpreted within the context of self-report, survey-based assessments, and the low response rate. Although these limitations and weaknesses of our study limit the generalizability of our results, this study attempts to address a critical knowledge gap regarding pre-deployment training of military nurses and medics. Our results may be used as a basis for conducting additional studies to gather more information on the state of pre-deployment training for nurses and medics. These studies will hopefully have a higher response rate and better quantify how many individuals received any form of pre-deployment training. Additionally, our recommendations regarding pre-deployment training that we derived from the study results may be helpful to military leadership. </jats:sec

Forward Surgical Team Procedural Burden and Non-operative Interventions by the U.S. Military Trauma System in Afghanistan, 2008–2014

Abstract Introduction No published study has reported non-surgical interventions performed by forward surgical teams, and there are no current surgical benchmarks for forward surgical teams. The objective of the study was to describe operative procedures and non-operative interventions received by battlefield casualties and determine the operative procedural burden on the trauma system. Methods This was a retrospective analysis of data from the Joint Trauma System Forward Surgical Team Database using battle and non-battle injured casualties treated in Afghanistan from 2008–2014. Overall procedure frequency, mortality outcome, and survivor morbidity outcome were calculated using operating room procedure codes grouped by the Healthcare Cost and Utilization Project classification. Cumulative attributable burden of procedures was calculated by frequency, mortality, and morbidity. Morbidity and mortality burden were used to rank procedures. Results The study population was comprised of 10,992 casualties, primarily male (97.8%), with a median age interquartile range of 25.0 (22.0–30.0). Affiliations were non-U.S. military (40.0%), U.S. military (35.1%), and others (25.0%). Injuries were penetrating (65.2%), blunt (32.8), and burns (2.0%). Casualties included 4.4% who died and 14.9% who lived but had notable morbidity findings. After ranking by contribution to trauma system morbidity and mortality burden, the top 10 of 32 procedure groups accounted for 74.4% of operative care, 77.9% of mortality, and 73.1% of unexpected morbidity findings. These procedure groups included laparotomy, vascular procedures, thoracotomy, debridement, lower and upper gastrointestinal procedures, amputation, and therapeutic procedures on muscles and upper and lower extremity bones. Most common non-operative interventions included X-ray, ultrasound, wound care, catheterization, and intubation. Conclusions Forward surgical team training and performance improvement metrics should focus on optimizing commonly performed operative procedures and non-operative interventions. Operative procedures that were commonly performed, and those associated with higher rates of morbidity and mortality, can set surgical benchmarks and outline training and skillsets needed by forward surgical teams. </jats:sec